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GC-335 Capacity Declaration - Conservatorship



Most of this form is to be filled out by the medical professional. This form can be filled out by the medical professional before and filed with the initial GC-310 “Petition for Appointment of Probate Conservator” or can be filed at a later date but before the court hearing for the conservatorship.

An important thing is that once you receive this document back from the medical professional be sure to review it for completeness. Make sure it is signed on page 1 and 3, and initial on page 3 if applicable. The printing and signing of the name on two pages can be overlooked. The place that needs to be initialed on page 3 is often overlooked.

Form Links

Filled in Example GC-335 Form- You can edit it to your situation print, and file it at your local California Superior Court. The form is the same as the one you can get from a California Superior Court Website.

Blank GC-335 Form

http://www.courts.ca.gov/forms.htm?filter=GC California Probate Conservatorship Complete List Downloadable

Content

The each page notes are below the respective image of the form page.

GC-335 Page 1 Notes

GC-335 Page 2 Notes

GC-335 Page 3 Notes

GC-335 Form in HTML so it can be Translated

GC-335 page 1

Page 1 Notes:

To Physician, Psychologist, or Religious Healing Practitioner Box
You need to fill out this box checking “A” and “B” along with the date of the hearing.

General Information

You can fill out the doctor’s name, address and telephone number or leave it to be filled out by the doctor.

The rest of this page is to be filled out, print name and signed by the medical professional.

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gc-335 page 2

Page 2 Notes:

Except for the header, page 2 is to be filled out by the medical professional.

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gc-335 page 3

Page 3 Notes:

Except for the header, page 3 is to be filled out, print name and signed by the medical professional.

Note the “Ability To Consent To Medical Treatment” if “7 b.” is checked, the medical professional must initial at “(Declarant must initial here if item 7b applies________)".

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GC-335 Form in HTML so it can be Translated

The GC-335 form is reproduced here in html so that it can easily be translated into multiple languages. You can not use this form to submit to court in any language. You have to use the GC-335 pdf form and English.

GC-335

 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar
 number, and address):

 NAME: John Doe & Jane Doe
 FIRM NAME:
 STREET ADDRESS: 1234 ABC Street
 CITY: San Francisco           STATE: CA           ZIP CODE: 94102
 TELEPHONE NO.: 415-123-4567          FAX NO.:
 E-MAIL ADDRESS: info@raisingautism.net
 ATTORNEY FOR (name): Petitioners, In Pro Per
 SUPERIOR COURT OF CALIFORNIA, COUNTY OF
 San Francisco
 STREET ADDRESS: 400 MCALLISTER STREET
 MAILING ADDRESS: 400 MCALLISTER STREET
 CITY AND ZIP CODE: SAN FRANCISCO, CA 94102
 BRANCH NAME: PROBATE
 CONSERVATORSHIP OF THE   small form box check   PERSON   small form box ESTATE OF (Name): Terry Morgan Doe

small form box CONSERVATEE small form box check PROPOSED CONSERVATEE

 Capacity Declaration -Conservatorship

 FOR COURT USE ONLY


















 CASE NUMBER:

        PCN-16-123456

 
TO PHYSICIAN, PSYCHOLOGIST, OR RELIGIOUS HEALING PRACTITIONER
The purpose of this form is to enable the court to determine whether the (proposed) conservatee (check all that apply):
A. small form box check  is able to attend a court hearing to determine whether a conservator should be appointed to care for him or
         her. The court hearing is set for (date):   March 7, 2016    . (Complete item 5, sign, and file page 1 of this
         form.)

B. small form box check  has the capacity to give informed consent to medical treatment. (Complete items 6 through 8, sign page 3,
         and file pages 1 through 3 of this form.)

C. small form box  has dementia and, if so, (1) whether he or she needs to be placed in a secured-perimeter residential care
         facility for the elderly, and (2) whether he or she needs or would benefit from dementia medications.
         (Complete items 6 and 8 of this form and form GC-335A; sign and attach form GC-335A. File pages 1
         through 3 of this form and form GC-335A.)

(If more than one item is checked above, sign the last applicable page of this form or form GC-335A if item C is checked. File page 1 through the last applicable page of this form; also file form GC-335A if item C is checked.)
COMPLETE ITEMS 1–4 OF THIS FORM IN ALL CASES.
GENERAL INFORMATION
1. Name): Doctors Name
2. (Office address and telephone number): Doctors address and telephone number


3. I am
    a. small form box check a California licensed small form box check physician small form box psychologist acting within the scope of my licensure
        small form box with at least two years' experience in diagnosing dementia.
    b. small form box an accredited practitioner of a religion whose tenets and practices call for reliance on prayer alone for healing,
            which religion is adhered to by the (proposed) conservatee. The (proposed) conservatee is under my
            treatment. (Religious practitioner may make the determination under item 5 ONLY.)
4. (Proposed) conservatee (name):
    a. I last saw the (proposed) conservatee on (date):
    b. The (proposed) conservatee small form box check is small form box is NOT a patient under my continuing treatment.
ABILITY TO ATTEND COURT HEARING
5. A court hearing on the petition for appointment of a conservator is set for the date indicated in item A above.
     (Complete a or b.)
    a. small form box check The proposed conservatee is able to attend the court hearing.
    b. small form box Because of medical inability, the proposed conservatee is NOT able to attend the court hearing (check all items
        below that apply)

        (1) small form box check on the date set (see date in box in item A above).
        (2) small form box for the foreseeable future.
        (3) small form box until (date):
        (4) Supporting facts (State facts in the space below or check this box small form box and state the facts in Attachment 5):




I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:    

            signature arrow
                         (TYPE OR PRINT NAME)                                             (SIGNATURE OF DECLARANT)                   

Page 1 of        

Form Adopted for Mandatory Use
Judicial Council of California
GC-335 [Rev. January 1, 2004]
CAPACITY DECLARATION -- CONSERVATORSHIP


Probate Code, § 811,
813, 1801, 1825
1881, 1910, 2356.5

 




GC-335
  small form box GUARDIANSHIP  small form box check CONSERVATORSHIP OF THE small form box check Person small form box Estate
  OF (name): Terry Morgan Doe

small form box MINOR small form box check PROPOSED CONSERVATEE   

  CASE NUMBER:

        PCN-16-123456

 
6. EVALUATION OF (PROPOSED) CONSERVATEE'S MENTAL FUNCTIONS

    Note to practitioner: This form is not a rating scale. It is intended to assist you in recording your impressions of
     the (proposed) conservatee's mental abilities. Where appropriate, you may refer to scores on standardized rating
     instruments.
    (Instructions for items 6A–6C): Check the appropriate designation as follows: a = no apparent impairment; b =
     moderate impairment; c = major impairment; d = so impaired as to be incapable of being assessed; e = I have
     no opinion.)


    A. Alertness and attention
        (1) Levels of arousal (lethargic, responds only to vigorous and persistent stimulation, stupor)
              a small form box be small form box c small form box d small form box    small form box  

        (2) Orientation (types of orientation impaired)
              a   small form box be small form box c small form box d small form box     small form box Person
              ad small form box be small form box c small form box    small form box     small form box Time (day, date, month, season, year)
              a   small form box be small form box c small form box d small form box     small form box Place (address, town, state)
              ad small form box be small form box c small form box    small form box     small form box Situation ("Why am I here?")

     (3) Ability to attend and concentrate (give detailed answers from memory, mental ability required to thread a needle)
               a   small form box be small form box c small form box d small form box      small form box 

    B. Information processing. Ability to:

        (1) Remember (ability to remember a question before answering; to recall names, relatives, past presidents, and
              events of the past 24 hours)
              i. Short-term memory      ad small form box be small form box c small form box   small form box   small form box  
              ii Long-term memory       a   small form box be small form box c small form box d small form box   small form box 
              iii Immediate recall           ad small form box be small form box c small form box    small form box   small form box 

        (2) Understand and communicate either verbally or otherwise (deficits reflected by inability to comprehend
              questions, follow instructions, use words correctly, or name objects; use of nonsense words)
              ad small form box be small form box c small form box    small form box    small form box 

        (3) Recognize familiar objects and persons (deficits reflected by inability to recognize familiar faces, objects, etc.)
              a   small form box be small form box c small form boxsmall form box    small form box 

        (4) Understand and appreciate quantities (deficits reflected by inability to perform simple calculations)
              ad small form box be small form box c small form box    small form box    small form box 

        (5) Reason using abstract concepts. (deficits reflected by inability to grasp abstract aspects of his or her situation
              or to interpret idiomatic expressions or proverbs)
              a   small form box be small form box c small form boxsmall form box    small form box 

        (6) Plan, organize, and carry out actions (assuming physical ability) in one's own rational self-interest (deficits
              reflected by inability to break complex tasks down into simple steps and carry them out)
              ad small form box be small form box c small form box    small form box    small form box 

        (7) Reason logically.
              a   small form box be small form box c small form boxsmall form box    small form box 

    C. Thought disorders
        (1) Severely disorganized thinking (rambling thoughts; nonsensical, incoherent, or nonlinear thinking)
              ad small form box be small form box c small form box    small form box    small form box 

        (2) Hallucinations (auditory, visual, olfactory)
              ad small form box be small form box c small form box    small form box    small form box 

        (3) Delusions (demonstrably false belief maintained without or against reason or evidence)
              ad small form box be small form box c small form box    small form box    small form box 

        (4) Uncontrollable or intrusive thoughts (unwanted compulsive thoughts, compulsive behavior).
              a  small form box be small form box c small form boxsmall form box    small form box 

(Continued on next page)

GC-335 [Rev. January 1, 2004]


CAPACITY DECLARATION -- CONSERVATORSHIP


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GC-335
  small form box GUARDIANSHIP  small form box check CONSERVATORSHIP OF THE small form box check Person small form box Estate
  OF (name): Terry Morgan Doe

small form box MINOR small form box check PROPOSED CONSERVATEE   

  CASE NUMBER:

        PCN-16-123456

 
6. (continued)
    D. Ability to modulate mood and affect. The (proposed) conservatee small form box has small form box does NOT have        a pervasive
         and persistent or recurrent emotional state that appears inappropriate in degree to his or her circumstances. (If
         so, complete remainder of item 6D.)
    small form box I have no opinion.
        (Instructions for item 6D: Check the degree of impairment of each inappropriate mood state (if any) as
         follows: a = mildly inappropriate; b = moderately inappropriate; c = severely inappropriate.)

         Anger     a small form box b small form box c small form box   Euphoria          a small form box b small form box c small form box   Helplessness a small form box b small form box c small form box
         Anxiety   a small form box b small form box c small form box   Depression      a small form box b small form box c small form box   Apathy         a small form box b small form box c small form box
         Fear        a small form box b small form box c small form box   Hopelessness  a small form box b small form box c small form box   Indifference   a small form box b small form box c small form box
         Panic       asmall form box b small form box c small form box    Despair           a small form box b small form box c small form box

     E. The (proposed) conservatee's periods of impairment from the deficits indicated in items 6A–6D
         (1) small form box do NOT vary substantially in frequency, severity, or duration.
         (2) small form box do vary substantially in frequency, severity, or duration (explain; continue on Attachment 6E if necessary):









     F. small form box (Optional) Other information regarding my evaluation of the (proposed) conservatee's mental function (e.g.,
             diagnosis, symptomatology, and other impressions) is small form box stated below small form box stated in Attachment 6F.








    ABILITY TO CONSENT TO MEDICAL TREATMENT
7. Based on the information above, it is my opinion that the (proposed) conservatee
    a. small form box has the capacity to give informed consent to any form of medical treatment. This opinion is limited to medical
            consent capacity.
    b. small form box check lacks the capacity to give informed consent to any form of medical treatment because he or she is either (1)
            unable to respond knowingly and intelligently regarding medical treatment or (2) unable to participate in a
            treatment decision by means of a rational thought process, or both. The deficits in the mental functions
            described in item 6 above significantly impair the (proposed) conservatee's ability to understand and appreciate
            the consequences of medical decisions. This opinion is limited to medical consent capacity.

(Declarant must initial here if item 7b applies:         .)

8.   Number of pages attached:    0   

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:    

            signature arrow
                         (TYPE OR PRINT NAME)                                             (SIGNATURE OF DECLARANT)                   


GC-335 [Rev. January 1, 2004]


CAPACITY DECLARATION -- CONSERVATORSHIP


Page 3 of 3


 
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